Radhika Tandon

Study of the psychosocial aspects of strabismus.

PURPOSE To systematically evaluate the perception of psychosocial difficulties due to strabismus and the impact of corrective surgery in adolescents and young adults in India. METHODS Patients 15 to 25 years of age with childhood onset (< or = 5 years of age) of constant concomitant squint (> or = 30 prism diopters of deviation for distance) were included in the study. After a detailed orthoptic evaluation, demographic data of the patients and their parents were recorded. Postgraduate Institute Health Questionnaire N-2 (standardized in India) was administered to rule out neuroticism in the patients. Psychosocial problems faced by the patients were evaluated with a semistructured interview schedule. Patients were evaluated 3 months after surgery using a similar interview schedule to assess the psychological impact of surgery. RESULTS Eighty percent of both male and female patients had problems in their social life; 85% of the males and 75% of the females had personal problems due to squint. After surgery, a positive change in appearance was noticed by 97.5% and 95% noticed a change in self-esteem and self-confidence. CONCLUSION These patients had difficulties with self-image and interpersonal relationships, faced ridicule at school and work, and generally avoided activities that brought attention to their defect. Substantial changes were noticed in them after corrective surgery, and the differences in their scores before and after surgery were statistically significant.

International Results with the Boston Type I Keratoprosthesis

PURPOSE To determine the indications and outcomes of Boston type 1 keratoprosthesis (Massachusetts Eye and Ear Infirmary, Boston, MA) surgery performed outside of North America and to compare them with those obtained in the United States by the surgeon who trained the international surgeons. DESIGN Retrospective review of consecutive clinical case series. PARTICIPANTS One hundred ninety-four patients (223 keratoprosthesis procedures performed in 205 eyes) who received Boston type 1 keratoprosthesis at 11 ophthalmology centers in Armenia, India, Indonesia, Nepal, Philippines, Russia, and Saudi Arabia between May 1, 2006, and July 1, 2011 (international series), and at the Jules Stein Eye Institute between May 1, 2004, and July 1, 2011 (University of California, Los Angeles [UCLA] series). METHODS Data were collected for each procedure regarding the preoperative characteristics of each eye, the surgical procedure(s) performed, and the postoperative outcomes. Statistical analysis was performed to identify significant differences between the international and UCLA series in terms of retention and complications. MAIN OUTCOME MEASURES Interval visual acuities, keratoprosthesis retention, and significant postoperative complications. RESULTS In the international series, 113 Boston type I keratoprostheses were implanted in 107 eyes of 100 patients. The most common indication for surgery was corneal graft failure (n = 50; 44%) followed by chemical injury (n = 30; 27%). Although only 2% of eyes had a preoperative corrected distance visual acuity (CDVA) of 20/20 to 20/200, 70%, 68%, and 59% of eyes had a postoperative CDVA of 20/20 to 20/200 at 6 months, 1 year, and 2 years after surgery, respectively. Ninety-one of the 113 keratoprostheses implanted (80.5%) were retained at a mean follow-up of 14.2 months, for a retention failure rate of 22 per 134.6 eye-years (0.163/eye-year). The most common postoperative complications were retroprosthetic membrane formation (27%) and sterile corneal necrosis (18%). The only postoperative complication that was more common in the international series than in the UCLA series was infectious endophthalmitis, which developed in 9% of eyes. CONCLUSIONS Boston keratoprosthesis is a viable means of managing repeat graft failure and ocular chemical injury outside of North America, with similar visual acuity outcomes, retention rates, and incidence rates of postoperative complications to those obtained by North American surgeons.

The osteo-odonto-keratoprosthesis (OOKP).

The osteo-odonto-keratoprosthesis (OOKP), although described over 40 years ago, remains the keratoprosthesis of choice for end-stage corneal blindness not amenable to penetrating keratoplasty. It is particularly resilient to a hostile environment such as the dry keratinized eye resulting from severe Stevens-Johnson syndrome, ocular cicatricial pemphigoid, trachoma, and chemical injury. Its rigid optical cylinder gives excellent image resolution and quality. The desirable properties of the theoretical ideal keratoprosthesis is described. The indications, contraindications, and patient assessment (eye, tooth, buccal mucosa, psychology) for OOKP surgery are described. The surgical and anaesthetic techniques are described. Follow-up is life-long in order to detect and treat complications, which include oral, oculoplastic, glaucoma, vitreo-retinal complications and extrusion of the device. Resorption of the osteo-odonto-lamina is responsible for extrusion, and this is more pronounced in tooth allografts. Regular imaging with spiral-CT or electron beam tomography can help detect bone and dentine loss. The optical cylinder design is discussed. Preliminary work towards the development of a synthetic OOKP analogue is described. Finally, we describe how to set up an OOKP national referral center.

Evaluation of umbilical cord serum therapy for persistent corneal epithelial defects

Aims: To evaluate umbilical cord serum therapy as a means of promoting the healing of persistent corneal epithelial defects. Methods: Umbilical cord serum or autologous serum drops were used to promote the healing of persistent epithelial defects. The study design was a prospective randomised controlled clinical trial. 60 eyes of 59 patients were divided into two groups, 31 in the cord serum group and 29 in the autologous serum control group. Epithelial defects measuring at least 2 mm in linear dimension resistant to conventional medical management were included. Serial measurements of the size of the epithelial defects—namely, two maximum linear dimensions perpendicular to each other, and the area and perimeter was done at start of therapy and follow up days 3, 7, 14, 21. Rate of healing of the epithelial defects were measured as percentage decrease from the baseline parameter at each subsequent follow up. The data were analysed by the non-parametric Wilcoxon rank sum test using STATA 7.0. Results: The median percentage decrease in the size of the epithelial defect was significantly greater in the cord serum group at days 7, 14 and 21 (p<0.05) when measured in terms of the area and perimeter. A greater number of patients showed complete re-epithelialisation with umbilical cord serum (n = 18) than with autologous serum (n = 11) (Pearson χ = 0.19). None of the patients reported any side effects or discomfort with either treatment. Conclusions: Umbilical cord serum leads to faster healing of the persistent corneal epithelial defects refractory to all medical management compared to autologous serum.

Causes and temporal trends of blindness and severe visual impairment in children in schools for the blind in North India

Aims: To describe the causes of severe visual impairment and blindness (SVI/BL) in children in schools for the blind in north India, and explore temporal trends in the major causes. Methods: A total of 703 children were examined in 13 blind schools in Delhi. A modified WHO/PBL eye examination record for children with blindness and low vision which included sections on visual acuity, additional non-ocular disabilities, onset of visual loss, the most affected anatomical part of the eye concerning visual impairment, and the aetiological category of the child’s disorder based on the timing of insult leading to visual loss was administered in all children. Results: With best correction, 22 (3.1%) were severely visually impaired (visual acuity in the better eye of <6/60) and 628 (89.3%) children were blind (visual acuity in the better eye of <3/60). Anatomical sites of SVI/BL were whole globe in 27.4% children, cornea 21.7%, retina 15.1%, and lens 10.9%. The underlying cause of visual loss was undetermined in 56.5% children (mainly abnormality since birth 42.3% and cataract 8.3%), childhood disorders were responsible in 28.0% (mainly vitamin A deficiency/measles 20.5%), and hereditary factors were identified in 13.4%. Study of temporal trends of SVI/BL by comparing causes in children in three different age groups—5–8 years, 9–12 years, and 13–16 years—suggests that retinal disorders have become more important while childhood onset disorders (particularly vitamin A deficiency) have declined. Conclusions: Almost half of the children suffered from potentially preventable and/or treatable conditions, with vitamin A deficiency/measles and cataract the leading causes. Retinal disorders seem to be increasing in importance while childhood disorders have declined over a period of 10 years.

Visual rehabilitation in end-stage inflammatory ocular surface disease with the osteo-odonto-keratoprosthesis: results from the UK

Aims: To report the long-term results of osteo-odonto-keratoprosthesis (OOKP) surgery in the visual rehabilitation of patients with corneal blindness from end-stage inflammatory ocular surface disease. Methods: A non-comparative retrospective case series of 36 consecutive patients treated at the National OOKP referral centre in Brighton, UK, between November 1996 and March 2006. Results: A total of 36 patients, with age ranging from 19 to 87 years (mean 51 (SD 19) years), were included in the analysis. The main preoperative diagnoses were Stevens–Johnson syndrome (n = 16, or 44%), severe thermal or chemical burns (n = 6, or 17%), and mucous membrane pemphigoid (n = 5, or 14%). The remainder of the cases comprised miscellaneous causes of dry eye (n = 9, or 25%), which included one each of graft versus host disease, ectodermal dysplasia, ionising radiation damage, cicatrising conjunctivitis from topical medication, trachoma, congenital trigeminal nerve hypoplasia, linear IgA disease, Sjögren syndrome and nutritional deficiency. Follow-up ranged from 6 months to 9 years (mean 3.9 (SD 2.5) years). Anatomical retention during the entirety of the follow-up period was seen in 72% of patients. The main factor resulting in anatomical failure was resorption of the OOKP lamina, which occurred in seven cases (or 19%). Predicted resorption in three cases resulted in successful planned exchange of the lamina, but two cases underwent emergency removal of the OOKP, and two cases developed endophthalmitis. Human leucocyte antigen-matched allografts suffered a higher rate of laminar resorption. Out of the entire cohort, 30 patients (or 83%) had some improvement in vision, 28 (or 78%) achieved vision of 6/60 or better, and 19 (or 53%) achieved 6/12 or better. The best-achieved vision was retained throughout the follow-up period in 61% of cases. Survival analysis suggested that the probability of retaining vision >6/60 5 years after surgery was 53 (10)%. Vision-threatening complications occurred in nine cases (or 25%) and included endophthalmitis, retinal detachment and glaucoma. De novo glaucoma occurred in six patients (or 24%) but was seen overall in 17 patients (or 47%), 10 of whom required surgical treatment. Conclusion: OOKP surgery can restore useful and lasting vision in patients suffering from end-stage ocular surface disease, for whom conventional corneal surgery is not possible. The main problems seen in this study were laminar resorption, particularly in allografts, and glaucoma.

Tectonic grafts for corneal thinning and perforations.

Purpose. To evaluate the success of tectonic grafts in cases of corneal thinning and perforations. Methods. We performed 42 tectonic grafts in 41 eyes of 40 patients. Three types of tectonic grafts were used in our treatment protocol. These were (a) full-thickness grafts, (b) mushroom grafts, and (c) lamellar grafts. The parameters evaluated were indications, visual acuity, location, size and type of graft, postoperative outcome, and complications, if any. Results. The most common indication for tectonic grafts was corneal thinning and perforation subsequent to infection (12 eyes) followed by those due to immunologic causes (six eyes) and trauma (six eyes). Twenty-four full-thickness tectonic grafts, nine mushroom grafts, and nine lamellar patch grafts were performed. Anatomical success was achieved in 35 of 41 (85.4%) eyes. Visual acuity of 6/24 or better was obtained in 29 of 41 (70.73%) eyes. The mean of best-corrected visual acuity (expressed in decimal) improved from 0.2 ± 0.26 to 0.34 ± 0.26 at an average follow-up of 10.83 ± 6.27 months. The major complications were peripheral anterior synechiae in four eyes (9.76%) and graft melting in five eyes (12.2%). Conclusions. Tectonic graft is a useful therapeutic option in selected cases of corneal thinning and perforations because it effectively restores the integrity of the eye and allows acceptable visual rehabilitation.

Evaluation of Umbilical Cord Serum Therapy in Acute Ocular Chemical Burns

PURPOSE To evaluate the role of umbilical cord serum therapy in cases of acute ocular chemical burns. METHODS In a double-blind prospective randomized controlled clinical study, 33 eyes of 32 patients with acute ocular chemical burns of grade III, IV, and V severity were randomized into three groups: umbilical cord serum (n = 12), autologous serum (n = 11), and artificial tears (0.5% HPMC+0.3% glycerin; n = 10). In addition, all eyes received standard medical therapy. The parameters evaluated were pain score, size, and area of epithelial defect, extent of limbal ischemia, corneal clarity, and symblepharon formation. The patients were followed up at day 1, 3, 7, 14, and 21 and at the end of months 1, 2, and 3. RESULTS Mean time to complete epithelialization was 21.16 ± 26.81, 56.6 ± 35.5, and 40.13 ± 35.79 days in cord serum, autologous serum, and artificial tears groups respectively (P = 0.02). By day 21, the mean percentage decrease in epithelial defect diameter was 94.63 ± 11.99 with cord serum compared with 53.17 ± 34.81 and 64.22 ± 42.43 with autologous serum and artificial tears, respectively (P = 0.01). By month 3, the extent of limbal ischemia with cord serum showed a mean percentage decrease of 73.43 ± 25.51 compared with 35.64 ± 25.60 and 43.71 ± 28.71 with autologous serum and artificial tears, respectively (P = 0.008). More patients had clear corneas with cord serum compared with autologous serum and artificial tears (P = 0.048). No significant difference was seen between the groups with regard to symblepharon formation (P = 0.07). CONCLUSIONS Umbilical cord serum therapy is more effective than autologous serum eye drops or artificial tears in ocular surface restoration after acute chemical injuries. (www.controlled-trials.com number, ISRCTN08131903.).

Factors affecting eye donation from postmortem cases in a tertiary care hospital

Purpose: To evaluate the responses to requests for eye donation from relatives of postmortem cases in a tertiary care hospital in India. Methods: In a prospective study, the cases brought for postmortem to the Forensic Medicine Department were screened as potential donors by our team. The next of kin of potential donors were approached and counseled in a systematic manner following a standard interview pattern. Responses were noted in a predesigned performa. The religion, level of literacy, socioeconomic status, relationship with the deceased, prior knowledge of eye donation, willingness for eye donation, and reasons for not donating eyes of the deceased were recorded. Results: One hundred fifty-nine potential donors were identified from a total of 721 postmortem cases. There were 119 (74.8%) men and 40 (25.2%) women. None of the deceased had previously pledged their eyes for eye donation. Eighty-eight (55.4%) next of kin were already aware of the concept of eye donation, but 71 (44.7%) families had not heard of it before. Willingness for eye donation was seen in 66 (41.5%), whereas 93 (58.5%) families refused eye donation. Of those already aware of eye donation, 39 (44.3%) gave consent for donation. Prior knowledge of eye donation had no influence on willingness for eye donation (P = 0.424). Similarly, literacy (P = 0.338) and socioeconomic status as estimated by a composite socioeconomic scale based on literacy and family income did not have any influence on willingness for eye donation (P = 0.338). Major reasons for not donating eyes included refusal to discuss the issue and dissuasion by distant relatives, legal problems, and religious beliefs. Conclusions: In our experience, literacy, socioeconomic status, and prior knowledge of eye donation of next kin had no correlation with donor corneal tissue procurement. Active counseling by a motivated team can be effective even in families with no prior knowledge and low socioeconomic status.

Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery.

Methods: Fifty children (age 5–14 years, ASA I–II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique.